The role of nutrition‐sensitive agriculture combined with behavioral interventions in childhood growth in Ethiopia: An adequacy evaluation study

Abstract Objective The study aimed to investigate the role of nutrition‐sensitive and specific interventions along with nutrition education on child stunting during the first 1000 days in Ethiopia. Methods An adequacy evaluation study was used to see changes between the baseline and end‐line data after following for 1 year. A sample of 170 mother‐child pairs who had a 1‐year followed up was used to detect differences. We performed structural equation modeling to elucidate changes in feeding behaviors, socioeconomic status, water, sanitation and hygiene on child linear growth. Furthermore, the independent effect of covariates on child linear growth was handled using a general linear model. Results A total of 170 and 270 mother‐child dyads were interviewed at baseline and end‐line surveys, respectively. After about 1 year of intervention, the annual rate of stunting prevalence declined from 29.3% (95% confidence interval [CI] = 18.6, 42.7) to 16.4% (95% CI = 10.7, 24.2). There was a significant change in the mean of length‐for‐age Z‐score which changed from −1.18 to −0.45 (P < .034). Adjusting for the different constructs of the health belief model, child sex, age, feeding behaviors, and dietary diversity, one egg consumption per day was responsible for the most significant variability explained (36%) for stunting reduction. Conclusions Sustainable access to egg consumption for children below 2 years experienced a substantial reduction in childhood stunting. A combination of nutrition‐sensitive agricultural and direct nutrition interventions along with behavioral‐based education is a sustainable strategy in reducing and preventing child growth from faltering in the early life stages.


| INTRODUCTION
Malnutrition among children under 5 years of age is still a widespread problem in many developing countries. 1 Child stunting, an indicator of chronic malnutrition, is a global public health problem and is both a symptom of past deprivation and a predictor of future poverty. 2 Failure to access essential nutrients during pregnancy and the first 2 years of life undermines the survival, growth, and development of children. 3,4 The number of stunted children has declined in all continents, except in Africa. 2 The etiology of early childhood malnutrition is complex, involving interactions between parental feeding practices, dietary intakes, and nutrient absorptive capabilities. Gastrointestinal and other infectious diseases, determined by a household and community's access to adequate water, sanitation, hygiene, and health services, increase nutritional needs and can further exacerbate malnutrition. 5,6 Poor diets drive malnutrition in early childhood. 2 Even though the stunting prevalence has demonstrated minimal progress in Ethiopia, 7 it imposed significant devastating impacts on individual health and community development. 8,9 Despite the execution of national nutrition programs and other programs by the government and bilateral organizations, stunting in Ethiopia is still a serious public health problem.
The global commitment to end all forms of malnutrition is addressed through the vivid application of nutrition intervention, which is comprised of nutrition-specific and -sensitive interventions.
Nutrition-specific interventions refer to interventions that address the immediate determinants of malnutrition while nutrition-sensitive interventions are designed for health interventions that influence the underlying determinants of nutrition. 10 Promoting the agricultural sector with a view of nutrition-sensitive productivity will assist in accelerating nutritional gains in the community, and enhance the production of diverse crops that enrich the quality of diets including micronutrient-rich foods. 10 Home gardens promote the production of nutrient-rich fruits and vegetables that can grow well in local conditions. 11 For appreciable health and nutrition impact, where nutrition-specific intervention alone cannot bring desirable change, nutrition-sensitive agricultural interventions should be coupled with behavior change communication campaigns. These all collectively improve knowledge on the importance of a healthy diet, dietary diversity, and best practices for food preparation, child feeding, and healthseeking behavior. 12 In Ethiopia, the available intervention strategies for the reduction of malnutrition are mainly focusing on direct nutrition-specific programs and poor integration with nutritionsensitive agriculture such as supporting the livelihood of rural households, promoting gender equality and nutrition education. The current intervention introduced the provision of egg-laying pullets, some ingredients for complementary food preparation, and vegetable seeds in addition. This study aimed to evaluate the contribution of nutritionsensitive agricultural interventions (home gardening and egg consumption) combined with behavioral-based nutrition and health education packages on the child feeding practices, hygiene and that leads to reduction of stunting in the rural area of Dessie, Ethiopia through the integration of community extension agents with the community.

| Intervention development
We established multidisciplinary experts from agriculture, health, communication, and social protection sectors to bring a behavioral change to prevent malnutrition and to have healthy individuals.
Given the causes of malnutrition by its nature are multifaceted and intertwined 13 ; we planned to design the intervention that integrates both nutrition-specific and nutrition-sensitive agriculture activities. Hence, the intervention process and the Health Belief Model (HBM) 14 provided the conceptual framework for the design and development of detailed compartments of the intervention packages.
The intervention framework integrates theory, practical evidence, and verifiable findings from reports and information collected from the target population to develop culturally appropriate and empirically sound interventions. 15 The six steps of intervention mapping were properly done to evaluate whether the goals of the intervention were achieved or not.
Then we evaluated the intervention performance and objective alignment by contextualizing local area features regarding knowledge, behavior, predisposing, and enabling factors (existing opportunities and threats) that attribute to wide practices of sub-optimal feeding patterns, deep-rooted malnutrition, and morbidities. A conceptual framework showing the inter-linkage between the expected outcomes and mediating factors for the improvement of child growth was modified and developed. 13,16,17 The best practical evidence from the literature 18-20 and a summary of theoretical methods 21 were used in the selection of existing methods and techniques. The HBM was used as the focus of behavioral change during the selection of behavior-based methods and strategies which has been widely employed in health and nutrition behavior change studies. 22

| Study participants and sampling procedure
We implemented the intervention in two selected Kebeles (namely, Abaso Kotu and Kolla Motie) with high malnutrition burden and rural food in-secured areas of South Wollo Zone, Ethiopia. Lactating mothers with their children below the age of 12 months were recruited to receive the intervention packages and followed up for 12 months. All lactating mothers with infants younger than 12 months and pregnant women and lived for at least 6 months were included in the study. All of the participants who fulfilled the inclusion criteria were registered for the intervention. We carried out adequacy evaluative intervention, which is recommended to compare the outcome in the target group with either previously defined goal or with changes observed in the target group following the intervention program, 23,24 to measure the contributions of our intervention in improving and sustaining maternal and child nutrition. The baseline survey was carried out in May 2019 and the end line survey was taken in April/May 2020 after 12 months of the period but with the same season.
The intervention was designed, by the end of the intervention program, to achieve the reduction of stunting by 20%. The sample size was determined using STATA version 15 by considering the percentage of change in length-for-age Z-score (LAZ) from a study in Malawi. 25 The baseline mean LAZ score was À1.81 with a SD of 1.1, and the end line SD and correlation were 1.15 and 0.65, respectively.
We had also assumed that 95% of confidence level, 80% of power and 10% of loss to follow up. Then the final sample size was found to be 170 mother-child dyads. During the baseline survey, a minimum of the above sample size was enrolled. However, any woman who delivered after the baseline survey was also registered and provided the intervention packages. As a result, during the end-of-intervention survey, there were 270 mother-child dyads.

| Interventions
The interventions were implemented in the first 1000 days plus of critical lifespans. To induce lasting behavior change, ensure continuity, and enhance the linkage between communities and health facilities, secondary target groups consisted of farmers, family members, women development army (WDA), agricultural development army or agent (ADA), health extension workers (HEW), and Kebeles administrators had been incorporated in the intervention. The intervention primarily applied nutrition and health education intervention that aimed to change feeding behavior, hygiene conditions, improving livelihood status, diversified diet, and nutrition. Frontline agents (HEWs and ADA) compiled all lists of program beneficiaries and called to participate in nutrition education which was voluntary and consent was sought from the caregivers before the commencement of the sessions. The intervention included five sessions (see Table S1) with both group training and demonstration.
The education was designed based on the findings obtained from the baseline survey and reshaped in accordance with recommendations from the Food and Agricultural Organization (FAO), 26 World Health Organization (WHO), 27 and United States of Children's Fund (UNICEF) 28 training resources. We developed the training materials both in the local language (Amharic) and the English language. Key messages on organic production, breastfeeding, complementary feeding, hygiene, and nutritious diet were published and distributed in the form of leaflets, brochures, posters, and manuals and the food pyramid was used to describe local available food groups customized from the national nutrition strategies of Ethiopia 29 and during each session, every participant was given posters, leaflets, and manuals to be used at their residential address. We made individual home-based followup sudden visits to assess the adoption of all participants to the training given following each session, to reinforce appropriate practices, and to correct mal-practices. The follow-up visits were conducted by the researcher and respective health workers and developmental agents from the intervention villages.
In addition to nutrition education, we also provided at least six egg-laying pullets, five types of vegetable seeds (cabbage, tomato, carrots, lettuce and spinach), and varieties of complementary foods (legumes, nuts, and some cereals), which are not produced in the areas but have the potential for intensified production in these environs.
The success of the nutrition education package was evaluated via baseline and end-line survey findings. Extensive process evaluation was also being performed to document the reach, dose, and fidelity of the intervention.

| Data collection and measurements
The baseline survey questionnaire, with additional questions targeting the nutrition education intervention, was administered during interviews with the caregivers. We recruited six data collectors and trained them on how to gather the information.
The questionnaire comprised of socio-demographic characteristics, the socioeconomic conditions, food security status, morbidity occasions, child breast and complementary feeding practices, maternal behavior regarding child feeding, water, sanitation and hygiene (WASH), and child anthropometric indices. The socio-economic status of the households was assessed by computing the wealth index based on the housing condition, the main source of drinking water, types of latrine, the main type of fuel, land ownership, and household assets (electricity, television, radio, watch, phone, bed, car, wagon, bicycle, bank account, and goat/sheep/cow/ox/horse).
We performed principal component analysis to classify the economic status into quintiles. 30 The change in food security status was also measured by the validated tool of the FAO guideline to categorize as food secured, mildly, moderately, and severely food secure. 31,32 To measure the difference in the child and maternal hygiene before and after the intervention, we assessed WASH components using nine-item questions with a score of one for those who fulfilled recommendations and zero for those who did not practice it properly. The WASH index was computed using the principal component analysis to divide the hygienic condition of children and mothers into terciles. 33 The contributions of the intervention on maternal or caregivers' behavioral change on feeding practice were assessed using the HBM, 34 which contained six components: perceived susceptibility, perceived severity, perceived benefit, perceived barriers, cue to action, and self-efficacy. To identify any observed change in behavior in the six constructs, we ran confirmatory factor analysis and judged based on the differences detected from the baseline findings.
The child dietary diversity score (CDDS) and minimum dietary diversity for woman (MDD-W) were determined from the 24-hours recalls. 35,36 The CDDS score ranges from zero to eight, and children who eat foods from five or more food groups daily were met the minimum recommended dietary diversity. 35 The variety of foods consumed by the children was further analyzed in detail using 14 food items. We also computed age-specific infant and young child feeding and other fruits. 36 The woman consumed five and above food groups per 24-hours of duration met the minimum recommendation.
To assess child nutritional status, weight, mid-upper arm circumference (MUAC) and length were measured during the baseline, monthly on the subsequent follow-up periods, and end-line survey.
Weight was taken using a well-calibrated and adjusted salter scale in the kilogram to the nearest 10 g and one digit after decimals. Recumbent length in centimeters was measured with a portable wood-made sliding board and recorded to the nearest 1 mm. MUAC was taken at the mid-point of the right arm of each child as recommended by WHO. Each measurement was obtained twice and results were averaged. If results were >3% discrepant, then a third measurement was obtained. Results were converted to Z-scores using WHO Anthro. 37

| Data analysis
Data were managed via digitalized electronic devices; stored as a form of comma-delimited file and exported to STATA/SE version 15 (StataCorp LP, College Station, Texas) for analysis. Frequency distributions were done to identify outliers. The descriptive statistics were done separately for the baseline and end-line data sets (meaning 170 mother-child pairs at baseline and 270 mother-child pairs at end line) ( Reliability analysis was performed for composite variables such as wealth index, WASH index, maternal behavior on child feeding and anthropometric measurements. Cronbach's alpha was used to assure the internal consistency of items which was greater than 0.7 for each composite variable. We also checked coefficient of variations, coefficient of reliability and technical error of measurement (TEM) for evaluating the validity of anthropometric measures.
Anthropometric indices such as weight-for-length Z-score (WLZ), length-for-age Z-score (LAZ), weight-for-age Z-score (WAZ), Body mass index-for-age Z-score (BAZ) and mid-upper arm circumferencefor-age Z-score (MUACZ) were generated using WHO Anthro version 3.2.2 growth standard. 31 Biologically implausible values based on WHO-recommended cutoffs at 6 SD were eliminated. The prevalence of stunting, wasting, and underweight were compared between the baseline and end-line. Changes in the mean score of the LAZ, WLZ, and WAZ were tested using a paired t test. The current average annual rate of reduction of stunting (AARR) was determined as AARR = 1 À (P t+n /P t ). Where P t+n is the latest prevalence of stunting after 1 year, P t is the starting year prevalence of stunting, and n is the number of years between them.
SEM was used to predict the status of child stature; path analysis General linear models with random intercepts and robust standard errors were used to assess for continuous repeated LAZ-score of children between the baseline and end-line data.
The effects of covariates for the difference in child LAZ (T1-T2) were evaluated through this model with the repeated measures of analysis of variance (ANOVA) at 95% of confidence level and coefficient of determination. The statistical significance level was declared at a P-value of less than .05.

| Characteristics of study participants
The intervention began with 170 mother-child pairs, and after a year, the project beneficiaries had grown 270 mother-child pairs. At baseline and end-line, the mean age (SD) of mothers was 28.28 (SD = 5.4) and 28.50 (SD = 5.98) years, respectively. The basic demographic, economic features and health service utilization of study participants at baseline and end-line survey were summarized in Table 2 below.
The average ages of children at baseline and end line were 6.5 (SD = 3.4) and 11.6 (SD = 5.8) months. The research participants' food insecurity levels differed from the baseline data, which showed a 5.2% reduction in food insecurity. Some incremental changes in health service coverage were observed in terms of antenatal care follow-up, Iron-Folic acid supplementations, child vaccinations, vitamin A and Zinc supplementations (Table 1).

| Maternal feeding behavior
Constructs of the HBM were used to assess the maternal feeding behaviors and awareness level on the impact of malnutrition. Six   Table S2).
The change responses of item scores for each component of the HBM were tested using paired-test statistics of the baseline and endline findings. The mean difference in item scores for the majority of the items under perceived susceptibility, severity, and benefit showed positive deviance from the baseline, which was significant at P < .05, whereas the change in the score of items under cue to action and self-efficacy, were negative and had an association at P < .05.
This indicates the change of maternal behaviors in terms of perceived susceptibility, severity, and benefit had positive improvement in the mean of the item scores, but item scores at the end line were decreased in the responses of the cue to action and self-efficacy (Table 2).

| Child feeding characteristics
There were no significant changes between baseline and end line sur- At the start of the study, 54.4% of youngsters fulfilled the minimal dietary diversity recommendation, and at the end, 77.5% did. Out of pair of 111 children, the mean dietary diversity score was significantly higher at the end-line (5.12) than the baseline (4.03), a difference of 1.1 and a P-value <.003 (Table 3). We compared the WHO-IYCF indicators as illustrated in Figure 2 and (Table 3).

| Predictors of child linear growth
The contribution of intervention had shown a substantial increment in the average LAZ score of children (paired-sample t test = À2.1, P = .034). The project employed nutrition-sensitive interventions such as nutrition education to change feeding behaviors of children and mothers and egg production for sustainable consumption. The independent effects of each of the components of interventions on childhood linear growth were determined by using the general linear model for the repeated measures of ANOVA (Table 4). Among all covariates adjusted for the model, only consumption of eggs on a daily basis influenced the LAZ score of children.
Consumption of an egg per day increases the child's LAZ score by1.12 units after 1 year of intervention. The variability of LAZ score after 1 year was, explained by the partial error term squares; egg consumption adjusted for other covariates changed by 36.4% (Table 4).
However, none of the HBM constructs showed a significant effect on child growth. 2) at the end-line in May 2020. The average annual reduction rate of stunting was 44%, indicating that the intervention was successful in meeting the study target. As a general rule, programs with an average annual reduction rate (AARR) of stunting of at least 3 (median AARR) from the baseline were considered effective. 39 This change was comparable with findings from a systematic review of interventional studies which ranged from 4.3% to 8.4%.

| DISCUSSION
In this project, nutrition-sensitive agriculture in combination with nutrition-counseling and specific interventions has shown a positive impact on child stature. Increasing agricultural production for human consumption helps to reduce stunting in children under the age of 2 years. The rate of thawing was best explained by eating at least one egg per day and having a higher kid dietary diversity score. Studies show that diets involving eggs significantly improve child growth, 40 because the egg is an excellent source of these nutrients (essential amino acids, lipids, and choline which play a significant role in child growth and development). 41 A randomized controlled trial in Ecuador revealed that the early introduction of eggs into child complementary foods reduced stunting by 47% (43) which supports the current findings that egg consumption increased LAZ-score by almost one unit (responsible for 36% of LAZ score increment). Furthermore, a recent review concludes that egg consumption affects not only the child's linear growth but also has a significant impact on brain development. 43 However, an experimental study in Bangladesh found that providing a daily egg to infants for 6 months had an effect on ponderal but not linear growth 44 and trials in Malawi and Zambia found that providing 1 egg per day to children had no overall effect on linear growth. 45 This finding was also congruent with the evidence that consumption of generic animal source foods (ASF) (dairy, meat/ fish, and egg) has a strong statistical association with stunting and such that consuming multiple ASFs is more advantageous than any single ASF. 46 These variations may be due to variability in the inter- ited. 51 Nutrition-sensitive agricultural projects (in particular home gardening, egg production) in Nepal and Bangladesh demonstrated significantly higher consumption of special foods such as eggs, meat, milk, nuts, and dried fruits, but no data on the impact of such foods on child anthropometric status was found. 11,51 Analysis of the situation in South Asia suggests that in the first 1000 days, it is critical to combine nutrition-sensitive therapies with a package of evidence-based direct nutrition interventions. 26,52 Women's empowerment and gender equality have a significant impact on women's health and nutrition. According to a recent report, a reduction in gender inequality would be beneficial, which could contribute to a 10 percentage points decline in stunting prevalence rate in children. 53 The study applied path analysis to identify direct and indirect associations between feeding behaviors and child linear growth. It also implemented intervention strategies that were devised taking into account community-specific concerns discovered through a variety of ways. The study's limitations include the inability to determine if the improvement was an independent consequence of the intervention we applied. It did not take into account the intervention group's changes in contrast to the other control groups and the existence of governments and non-government intervention programs in the area may mask the realistic intervention effect on child growth.
Quantitative estimation of child nutrient intakes and micronutrient deficiencies were not assessed in the study.

| CONCLUSIONS
We concluded that the combination of nutrition-sensitive agriculture and nutrition-specific interventions improve child growth. A child's linear growth outcome by LAZ was reduced by about 13% from the baseline finding. Adjusted by sex, age, and some other variables, the daily basis of egg consumption during the first 1000 days significantly improved linear growth and reduced stunting. Socio-cultural phenomena, maternal and child feeding behavior, individual diversity, access to water, sanitation and hygiene, food insecurity, morbidity status, and health service utilization did not significantly impact child stature but may have a mediator effect on the pathway of malnutrition.
Given the complex nature of these diverse intervention packages, strong political commitment, multi-sectoral collaboration, community-based service delivery platforms, and wider program coverage and compliance are all likely critical components of effective stunting reduction programs.  were funded the research. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

CONFLICT OF INTEREST
The authors declare that they have no competing interests related to authorship and financial issues. All authors contributed to data analysis, drafting or revising the article, have agreed on the journal to which the article will be submitted, gave final approval of the version to be published, and agree to be accountable for all aspects of the work.

DATA AVAILABILITY STATEMENT
The datasets generated and/or analyzed during the current study are not publicly available due to the lack of databases in our institution but are available from the corresponding author on reasonable request.

TRANSPARENCY STATEMENT
We declare that the scientific report is our original work with appropriate acknowledgements and recognition of others' work used for the development of the manuscript. Parts or whole section of figures, texts, or tables included in this manuscript are not submitted to other journals for publication.

ETHICS STATEMENT
Ethical clearance was obtained from the ethical review board of Wollo University, College of Medicine and Health Sciences. Permission was obtained from local district leaders. Each study participant was communicated clearly about the objective of the study in order to obtain their verbal consent, their full right to withdraw or refuse to participate. Privacy and confidentiality of information taken from each study participant were handled in a secured manner.